"We are planning on it, but don't have a date certain," Pai said, noting that there would have to be a universal coding and billing database that compared all processes the same. "And then, if you drill down to physician level, you have volume differences and patient demographic differences ... Reporting would be difficult. We are very cautious," he said.

The Massachusetts Medical Society filed a lawsuit in May to halt such an evaluation process in that state, saying the methodology is flawed and has defrauded patients.

The Massachusetts Group Insurance Commission, the agency that oversees health insurance for thousands of public employees there, implemented a report card two years ago and has been haggling with the MMS ever since.

A large part of the issue is that doctors who see sicker patients are more likely to be ranked lower on the scale, because of worse outcomes.

In addition, the system is so cumbersome, the MMS said, that incorrect treatment information had been included in the database as well.

Tennessee Blue Cross Blue Shield halted it's own program earlier this year for those same problems.

HAP introduced a ranking on quality of health systems three years ago, Pai said, and that was the result of several years of collaboration and working with the systems for feedback and advice.

That collaborative effort got the various players to buy into the idea, and built trust that a fair system is in place, he said.

"Once we put out the public report, we had callbacks from physicians and (health) leaders saying, 'I want to be better than X, so what can we do to get a better rating?' So this was a healthy competition built in without animosity," Pai said.

A next step could be individual physician report cards, Pai said, but there are so many variables that it has to be done properly or risk a backlash more problems.

The Michigan State Medical Society has released a set of guidelines in the event that any agency or organization attempts to compile that data.

Grand Rapids-based health plan Priority Health started a rating program for its provider doctors three years ago, and will not rate a physician if he or she does not see enough Priority patients.

The health plan has a set of criteria that considers preventive practices, disease management, health screening, immunizations and patient satisfaction, said spokeswoman Juanita Smith.

Some scores are based not on the individual doctor's patients, but on the patients of all doctors who practice together.

The system formulates a percentage and assigns from one to four apples.

The first year, 12 physicians were in the top, the second year, 30 were in the top and last year 59 doctors earned four apples.

Priority has a feedback system for the physicians to discuss guidelines and how to attain higher rankings, Smith said.

"I do believe that physicians respond to measurement, we are competitive, we value the care we give our patients, we all ask 'how am I doing?'" said Dr. Greg Forzley, chairman of the board of the Michigan State Medical Society and medical director informatics at St. Mary's Health Care in Grand Rapids.

Forzley helped develop the Priority concept in its early stages and he calls it a fairly good system, but it only deals with the Priority population.

"The challenge has been some of the measures are very narrowly defined and don't cover the entire patient base," Forzley said. "It would be best to find how the patients are doing overall."

He also noted that processes and outcomes will be different in different geographical areas and might vary greatly between an urban community and an affluent suburban community. Those differences are hard to reconcile, Forzley said.

The Michigan Department of Community Health compiles information about disciplinary action and factual data about the health industry, but "We don't have a ranking for individual doctors," spokesman James McCurtis said. "For the state to get involved would put us in a lot of liability issues.

With more than 39,000 physicians in the state, compiling a comprehensive list would be cumbersome and fraught with problems, McCurtis said.

"For one it would be biased and would do a disservice to the profession and it wouldn't do anything but create tension," he said.